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JOINT POLICY STATEMENT
EQUIPMENT FOR GROUND AMBULANCES
American Academy of PediatricsAmerican College of Emergency Physicians
American College of Surgeons Committee on TraumaEmergency Medical Services for Children
Emergency Nurses AssociationNational Association of EMS Physicians
National Association of State EMS Officials
Four decades ago, the Committee on Trauma of theAmerican College of Surgeons (ACS) developed alist of standardized equipment for ambulances. In1988, the American College of Emergency Physicians(ACEP) published a similar list. The two organiza-tions collaborated on a joint document published in2000, and the National Association of EMS Physi-cians (NAEMSP) participated in the 2005 revision. The2005 revision included resources needed on emergencyground ambulances for appropriate homeland secu-rity. All three organizations adhere to the principle thatemergency medical services (EMS) providers at all lev-els must have the appropriate equipment and suppliesto optimize out-of-hospital delivery of care. The docu-ment was written to serve as a standard for the equip-ment needs of emergency ground ambulance servicesboth in the United States and Canada.
EMS providers care for patients of all ages whohave a wide variety of medical and traumatic condi-tions. The 2009 revision included updated pediatricrecommendations developed by members of the Fed-eral Emergency Medical Services for Children (EMSC)Stakeholder Group and endorsed by the AmericanAcademy of Pediatrics (AAP). The EMSC program hasdeveloped several performance measures for the pro-gram’s state partnership grantees. One of the perfor-mance measures evaluates the availability of essen-tial pediatric equipment and supplies for basic life
Declaration of Interest: Organizations participating in this joint pol-icy statement, and their representatives to the working group thatdrafted it, report no conflicts of interest.
doi: 10.3109/10903127.2013.851312
support (BLS) and advanced life support (ALS) pa-tient care units. This document is used as the standardfor this performance measure. The National Associa-tion of State EMS Officials and the Emergency NursesAssociation have participated in the latest revisionprocess. The recommendations in this documentspecifically pertain to ALS and BLS emergency groundambulance services in the United States.
For purposes of this document, the following defini-tions have been used: a neonate is 0–28 days old, aninfant is 29 days to 1 year old, and a child is >1 yearthrough 11 years old with delineation into the follow-ing developmental stages:
Toddlers (1–2 years old)Preschoolers (3–5 years old)Middle childhood (6–11 years old)Adolescents (12–18 years old)
These standard definitions are age based. Length-based systems have been developed to more accuratelyestimate the weight of children and predict appropri-ate equipment sizes, medication doses, and guidelinesfor fluid volume administration.
PRINCIPLES OF OUT-OF-HOSPITAL CARE
The goal of out-of-hospital care is to minimize fur-ther systemic injury and manage life-threatening con-ditions through a series of well-defined and appropri-ate interventions and to embrace principles that ensurepatient safety. High-quality, consistent emergency caredemands continuous quality improvement and is di-rectly dependent on the effective monitoring, integra-tion, and evaluation of all components of the patient’scare.
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EQUIPMENT FOR AMBULANCES 93
Integral to this process is medical oversight of out-of-hospital care by using preexisting patient care pro-tocols (indirect medical oversight), which are evidencebased when possible, or by medical control via voiceand/or video communication (direct medical over-sight). The protocols that guide patient care shouldbe established collaboratively by medical directors forground ambulance services, adult and pediatric emer-gency medicine physicians, adult and pediatric traumasurgeons, and appropriately trained basic and ad-vanced emergency medical personnel. Current recom-mendations of the Institute of Medicine (IOM) encour-age each EMS agency to have a pediatric coordinatorto specifically coordinate the capability of the serviceto care for non-adult patients.
EQUIPMENT AND SUPPLIES
The current guidelines provide a recommendedcore list of supplies and equipment that shouldbe stocked on ground ambulances to provide theaccepted standards of patient care. Equipment re-quirements will vary, depending on the certifica-tion or licensure levels of the providers (as definedby the National EMS Scope of Practice Model 2007www.ems.gov/education/EMSScope.pdf), local med-ical direction and jurisdiction, population densities,geographic and economic conditions of the region, andother factors.
The National EMS Scope of Practice Model de-fines and describes four certification or licensurelevels of EMS provider: emergency medical respon-der (EMR), emergency medical technician (EMT), ad-vanced EMT (AEMT), and paramedic. Each level rep-resents a unique role, set of skills, and knowledge base.The National EMS Scope of Practice Model establishesa framework that ultimately determines the range ofskills and roles that an individual possessing a stateEMS license is authorized to do in a given EMS system.Individual state EMS rules or regulations that limitprovider scope of practice may impact the need foravailability of certain pieces of equipment.
The current equipment list is derived from a num-ber of sources, which may be found in the referencelist at the end of the document. The use of a propri-etary name that is inextricably linked with its productshould not be construed as an endorsement.
The following list is divided into equipment for ba-sic life support (BLS) and advanced life support (ALS)emergency ground ambulances. ALS ambulances musthave all of the equipment on the required BLS list aswell as equipment on the required ALS list. This listrepresents a consensus of recommendations for equip-ment and supplies that will facilitate patient care in theout-of-hospital setting.
REQUIRED EQUIPMENT FOR BLS EMERGENCY
GROUND AMBULANCES
A. Ventilation and Airway Equipment1. Portable and fixed suction apparatus with a
regulator, per federal specifications• Wide-bore tubing, rigid pharyngeal curved
suction tip; tonsil and flexible suctioncatheters, 6F–16F, are commercially available(have one between 6F and 10F and one be-tween 12F and 16F)
2. Portable oxygen apparatus, capable of meteredflow with adequate tubing
3. Portable and fixed oxygen supply equipment• Variable flowmeter
4. Oxygen administration equipment• Adequate-length tubing; transparent mask
(adult and child sizes), both non-rebreathingand valveless; nasal cannulas (adult, child)
5. Bag-valve mask (manual resuscitator)• Hand-operated, self-expanding bag; adult
(>1000 mL) and child (450–750 mL) sizes,with oxygen reservoir/accumulator, valve(clear, operable in cold weather), and mask(adult, child, infant, and neonate sizes)
6. Airways• Nasopharyngeal (16F–34F; adult and child
sizes)• Oropharyngeal (sizes 0–5; adult, child, and
infant sizes)7. Pulse oximeter with pediatric and adult probes8. Saline drops and bulb suction for infants
B. Monitoring and DefibrillationBLS ground ambulances should be equipped withan automated external defibrillator (AED) unlessstaffed by advanced life support personnel whoare carrying a monitor/defibrillator. The AEDshould have pediatric capabilities, includingchild-sized pads and cables OR dose attenuatorwith adult pads.
C. Immobilization Devices1. Cervical collars
• Rigid for children ages 2 years or older; childand adult sizes (small, medium, large, andother available sizes) OR pediatric and adultadjustable cervical collars
2. Head immobilization device (not sandbags)• Firm padding or commercial device
3. Upper and lower extremity immobilizationdevices• Joint-above and joint-below fracture (sizes
appropriate for adults and children) rigidsupport, constructed with appropriate mate-rial (cardboard, metal, pneumatic, vacuum,wood, or plastic)
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4. Impervious backboards (long, short; radiolu-cent preferred) and extrication device• Short extrication/immobilization device
(e.g., KED)• Long transport (head-to-feet length) with
at least 3 appropriate restraint straps (chinstrap alone should not be used for head im-mobilization) and with padding for childrenand handholds for moving patients
D. Bandages/Hemorrhage Control
1. Commercially packaged or sterile burn sheets2. Bandages
• Triangular bandages3. Dressings
• Sterile dressings, including gauze sponges ofsuitable size
• Abdominal dressing4. Gauze rolls
• Various sizes5. Occlusive dressing or equivalent6. Adhesive tape
• Various sizes (including 1′′ and 2′′) hypoal-lergenic
• Various sizes (including 1′′ and 2′′) adhesive7. Arterial tourniquet (commercial preferred)
E. Communication
Two-way communication device between groundambulance, dispatch, medical control, andreceiving facility
F. Obstetrical Kit (commercially packaged areavailable)
1. Kit (separate sterile kit)• Towels, 4′′ × 4′′ dressing, umbilical tape,
sterile scissors or other cutting utensil, bulbsuction, clamps for cord, sterile gloves,blanket
2. Thermal absorbent blanket and head cover,aluminum foil roll, or appropriate heat-reflective material (enough to cover newborninfant)
G. Miscellaneous
1. Access to pediatric and adult patient careprotocols
2. A length-based resuscitation tape OR a refer-ence material that provides appropriate guid-ance for pediatric drug dosing and equipmentsizing based on length OR age
3. Sphygmomanometer (pediatric and adultregular size and large cuffs)
4. Adult stethoscope5. Thermometer with low-temperature
capability6. Heavy bandage or paramedic scissors for cut-
ting clothing, belts, and boots
7. Cold packs8. Sterile saline solution for irrigation9. Two functional flashlights
10. Blankets11. Sheets (at least one change per cot)12. Pillows13. Towels14. Triage tags15. Emesis bags or basins16. Urinal17. Wheeled cot18. Stair chair or carry chair19. Patient care charts/forms or electronic
capability20. Lubricating jelly (water soluble)
H. Infection Control∗1. Eye protection (full peripheral glasses or gog-
gles, face shield)2. Face protection (e.g., surgical masks per appli-
cable local or state guidance)3. Gloves, nonsterile4. Fluid-resistant overalls or gowns5. Waterless hand cleanser, commercial antimi-
crobial (towelette, spray, or liquid)6. Disinfectant solution for cleaning equipment7. Standard sharps containers, fixed and portable8. Biohazard trash bags (color coded or with
biohazard emblem to distinguish from othertrash)
9. Respiratory protection (e.g., N95 or N100mask—per applicable local or state guidance)
∗Latex-free equipment should be available
I. Injury-prevention Equipment
1. Availability of necessary age/size-appropriaterestraint systems for all passengers and pa-tients transported in ground ambulances. Forchildren, this should be according to the Na-tional Highway Traffic Safety Administration’sdocument: Safe Transport of Children in Emer-gency Ground Ambulances (www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf)
2. Fire extinguisher3. Department of Transportation Emergency Re-
sponse Guide4. Reflective safety wear for each crewmember
(must meet American National Standard forHigh Visibility Public Safety Vests if workingwithin the right of way of any federal-aidhighway. Visit www.reflectivevest.com/federalhighwayruling.html for moreinformation)
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EQUIPMENT FOR AMBULANCES 95
REQUIRED EQUIPMENT: ADVANCED LIFE
SUPPORT (ALS) EMERGENCY GROUND
AMBULANCES
For paramedic services, include all of the requiredequipment listed above, plus the following additionalequipment and supplies. For advanced EMT services(and other non-paramedic advanced levels), includeall of the equipment from the above list and selectedequipment and supplies from the following list, basedon scope of practice, local need, and consideration ofout-of-hospital characteristics and budget.
A. Airway and Ventilation Equipment
1. Laryngoscope handle with extra batteries andbulbs
2. Laryngoscope blades, sizes:a. 0–4, straight (Miller), andb. 2–4, curved
3. Endotracheal tubes (if ALS service scope ofpractice includes tracheal intubation), sizes:
a. 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, and 5.5 mm cuffedand/or uncuffed, and
b. 6.0, 6.5, 7.0, 7.5, and 8.0 mm cuffed (1 each),other sizes optional
4. 10-mL non-Luer Lock syringes5. Stylettes for endotracheal tubes, adult and
pediatric6. Magill forceps, adult and pediatric7. End-tidal CO2 detection capability (adult and
pediatric)8. Rescue airway device, such as the ETDLA
(esophageal–tracheal double-lumen airway),laryngeal tube, disposable supraglottic airway,or laryngeal mask airway (as approved by lo-cal medical direction)
B. Vascular Access
1. Isotonic crystalloid solutions2. Antiseptic solution (alcohol wipes and
povidone–iodine wipes preferred)3. Intravenous fluid bag pole or roof hook4. Intravenous catheters, 14G–24G5. Intraosseous needles or devices appropriate
for children and adults6. Latex-free tourniquet7. Syringes of various sizes8. Needles, various sizes (including suitable
sizes for intramuscular injections)9. Intravenous administration sets (microdrip
and macrodrip)10. Intravenous arm boards, adult and pediatric
C. Cardiac
1. Portable, battery-operated monitor/defibri-llator
• With tape write-out/recorder, defibrillatorpads, quick-look paddles or electrode, orhands-free patches, electrocardiogram leads,adult and pediatric chest attachment elec-trodes, adult and pediatric paddles
2. Transcutaneous cardiac pacemaker, includingpediatric pads and cables• Either stand-alone unit or integrated into
monitor/defibrillatorD. Other Advanced Equipment
1. Nebulizer2. Glucometer or blood glucose measuring de-
vice with reagent strips3. Long large-bore needles or angiocatheters
(should be at least 3.25” in length for needlechest decompression in large adults)
E. MedicationsDrug dosing in children should use processesminimizing the need for calculations, preferably alength-based system. In general, medications mayinclude:1. Cardiovascular medication, such as 1:10,000
epinephrine, atropine, antidysrhythmics (e.g.,adenosine and amiodarone), calcium channelblockers, beta-blockers, nitroglycerin tablets,aspirin, vasopressor for infusion
2. Cardiopulmonary/respiratory medications,such as albuterol (or other inhaled betaagonist) and ipratropium bromide, 1:1000epinephrine, furosemide
3. 50% dextrose solution (and sterile diluent or25% dextrose solution for pediatrics)
4. Analgesics, narcotic and nonnarcotic5. Anti-epileptic medications, such as diazepam
or midazolam6. Sodium bicarbonate, magnesium sulfate,
glucagon, naloxone hydrochloride, calciumchloride
7. Bacteriostatic water and sodium chloride forinjection
8. Additional medications, as per local medicaldirector
OPTIONAL EQUIPMENT
The equipment in this section is not mandated orrequired. Use should be based on local needs andresources.
A. Optional Equipment for BLS Ground Ambu-lances
1. Glucometer or blood glucose test strips (perstate protocol and/or local medical controlapproval)
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2. Infant oxygen mask3. Infant self-inflating resuscitation bag4. Airways
a. Nasopharyngeal (12F, 14F)b. Oropharyngeal (size 00)
5. CPAP/BiPAP capability6. Neonatal blood pressure cuff7. Infant blood pressure cuff8. Pediatric stethoscope9. Infant cervical immobilization device
10. Pediatric backboard and extremity splints11. Femur traction device (adult and child sizes)12. Pelvic immobilization device13. Elastic wraps14. Ocular irrigation device15. Hot packs16. Warming blanket17. Cooling device18. Soft patient restraints19. Folding stretcher20. Bedpan21. Topical hemostatic agent/bandage22. Appropriate CBRNE PPE (chemical, biologi-
cal, radiological, nuclear, explosive personalprotective equipment), including respiratoryand body protection; protective helmet/jackets or coats/pants/boots
23. Applicable chemical antidote auto-injectors(at a minimum for crew members’ protection;additional for victim treatment based on localor regional protocol; appropriate for adultsand children)
B. Optional Equipment for ALS Emergency GroundAmbulances
1. Respirator, volume-cycled, on/off operation,100% oxygen, 40–50 psi pressure (child/infantcapabilities)
2. Blood sample tubes, adult and pediatric3. Automatic blood pressure device4. Nasogastric tubes, pediatric feeding tube sizes
5F and 8F, sump tube sizes 8F–16F5. Size 1 curved laryngoscope blade6. Gum elastic bougies7. Needle cricothyrotomy capability and/or
cricothyrotomy capability (surgical cricothy-rotomy can be performed in older children inwhom the cricothyroid membrane is easilypalpable, usually by puberty)
8. Rescue airway devices for children9. Atomizers for administration of intranasal
medications
OPTIONAL MEDICATIONS
A. Optional Medications for BLS Emergency Ambu-lances
1. Albuterol2. Epi-pen3. Oral glucose4. Nitroglycerin (sublingual tablet or paste)5. Aspirin
B. Optional Medications for ALS EmergencyGround Ambulances1. Intubation adjuncts, including neuromuscular
blockers
INTERFACILITY TRANSPORT
Additional equipment may be needed by ALS andBLS out-of-hospital care providers who transport pa-tients between facilities. Transfers may be made toa lower or higher level of care, depending on thespecific need. Specialty transport teams, includingpediatric and neonatal teams, may include other per-sonnel, such as respiratory therapists, nurses, andphysicians. Training and equipment needs may be dif-ferent depending on the skills needed during transportof these patients. There are excellent resources avail-able that provide detailed lists of equipment neededfor interfacility transfer, such as Guidelines for Air andGround Transport of Neonatal and Pediatric Patientsfrom the AAP and The Interfacility Transfer Toolkit forthe Pediatric Patient from the EMSC, ENA, and the So-ciety of Trauma Nurses.
Any ground ambulance that, either by formal agree-ment or by circumstance, may be called into serviceduring a disaster or mass casualty incident to treatand/or transport any patient from the scene to the hos-pital or to transfer between facilities any patient otherthan those within their designated specialty popula-tion should carry, at a minimum, all equipment, adultand pediatric, listed under “Required Equipment forAll Emergency Ground Ambulances.”
EXTRICATION EQUIPMENT
In many cases, optimal patient care mandates appro-priate and safe extrication or rescue from the patient’ssituation or environment. It is critical that EMS person-nel possess or have immediate access to the expertise,tools, and equipment necessary to safely remove pa-tients from entrapment or hazardous environments. Itis beyond the scope of this document to describe theextent of these. Local circumstances and regulationsmay affect both the expertise and tools that are main-tained on an individual ground ambulance, and on anyother rescue vehicle that may be needed to accompanyan ambulance to an EMS scene. The tools and equip-ment carried on an individual ground ambulance needto be thoughtfully determined by local features of theEMS system with explicit plans to deploy the neededresources when extrication or rescue is required.
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